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Year : 2013  |  Volume : 2  |  Issue : 1  |  Page : 25-28

Necrotizing fasciitis: Role of counter irritants in the etiology

Department of General Surgery, Rangaraya Medical College, Kakinada, Andhra Pradesh, India

Date of Web Publication13-Mar-2013

Correspondence Address:
Bhavani Rao Reddi
Andhra Medical college, Vishakhapattanam, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2277-8632.108509

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Background: Necrotizing fasciitis (NF) is a common presenting problem in septic wards of Government hospitals. Ignorance plays a role in application of counter irritants as a remedy for minor ailments, which may result in necrotizing fasciitis.
Aim: A pilot study was conducted to identify an association between application of counter irritants and subsequent development of NF.
Materials and Methods: Patients presented with features of NF were queried with a structured pro forma regarding application of counter irritants.
Results: Seventy six out of One Hundred and Ten patients confessed to application of various aromatic resinous substances.
Conclusion: There is a strong index of suspicion that irritant balms may be one of the etiological agent or an aggravating factor in causation of NF.

Keywords: Counter irritants, necrotizing fasciitis, etiology

How to cite this article:
Reddi BR, Korukonda B, Palanki G. Necrotizing fasciitis: Role of counter irritants in the etiology. J NTR Univ Health Sci 2013;2:25-8

How to cite this URL:
Reddi BR, Korukonda B, Palanki G. Necrotizing fasciitis: Role of counter irritants in the etiology. J NTR Univ Health Sci [serial online] 2013 [cited 2022 Jan 16];2:25-8. Available from: https://www.jdrntruhs.org/text.asp?2013/2/1/25/108509

  Introduction Top

Necrotizing fasciitis (NF) is a spreading infection accompanied by painful edema, at times with blister formation. It was initially expressed by Hippocrates in the fifth century as erysipelas. [1] It was termed as gangrenous ulcer, putrid ulcer, phagedena, phagedenic ulcer, phagedena gangrenosa, and hospital gangrene [2] In 1924, Meleney applied the label hemolytic streptococcal gangrene [3] Since then, various names have been given to NF. Lastly, in 1952, Wilson used the term NF. The anogenital manifestation of NF was depicted by Fournier in 1883. In the literature various reasons have been related to the primary focus and include minor skin lesions, bites of insects, and wounds after surgical procedures. [4],[5],[6],[7],[8] No references could be found on the role of counter irritants in the etiology of NF. In a study conducted at a teaching hospital college, Andhra Pradesh, role of counter irritant as a possible cause or aggravating factor for NF is suggested.

  Materials and Methods Top

This study was undertaken in Department of General Surgery, Government General Hospital, Kakinada, Andhra Pradesh between March 2009 and April 2011 for a period of 2 years. A format was prepared for collecting data from the patients. Thorough history was taken regarding fever, trauma, insect bite, intravenous drug abuse, recent surgery, burns, non-steroid anti inflammatory drugs (NSAIDS) use and application of counter irritant. Patients with ischemic limbs because of atherosclerosis and thromboangitis obliterans were excluded from the study. Diagnostic criteria modified by Fischer was utilized for making a diagnosis of NF. [9]

  Results Top

Total of 110 cases of NF were observed during the study period. Males were more (65%) and the median age was 46 (8-65) years [Figure 1]. Lower limb and perineum were commonly involved sites [Figure 2]. 76 persons applied the counter irritant. The nature of these irritants included different Ayurvedic proprietary preparations containing Wintergreen oil, Pudina oil, Cinnamomum, camphora etc.
Figure 1: Age distribution of necrotizing fasciitis

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Figure 2: Involved body area distribution of necrotizing fasciitis

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Most patients were manual laborers and applied the balm for the relief of muscle aches and others used it for curing minor cuts, ulcers or skin diseases. Five brands were popular and their composition was given in [Table 1]. Another common practice was to apply camphor powder in coconut oil over aching muscles.
Table 1: Various brand names and common ingradients

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There was disproportionate pain over the medicament applied area within 24-48 h and tenderness beyond cutaneous erythema [Figure 3]. The depth of the lesion was more when the balm was applied for longer duration and as a thick layer. The epidermis showed blister formation and could be easily peeled off. Lurking deep to the dermis was yellowish white liquefied subcutaneous tissues turned into jelly of thick pus [Figure 4]. After repeated slough excisions and after a week healthy granulation tissue appeared from floor of the lesion [Figure 5] and [Figure 6]. Diabetes mellitus was a frequent co-morbid factor [Figure 7].
Figure 3: Cutaneous erythema

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Figure 4: Yellowish white liquefi ed subcutaneous tissues turned into jelly of thick pus

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Figure 5: After slogh excision

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Figure 6: Healthy granulation tissue after few weeks

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Figure 7: Co-morbid factors of necrotizing fasciitis

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Necrotising fasciitis was correctly diagnosed at the time of admission in only 27.2% of patients. The initial diagnosis was made as cellulitis in 58%, as vascular gangrene in 9% and as abscess in about 5%. Mixed infection (43.63%) was the usual culture report. Gram-positive aerobic bacteria, Streptococci group A, Streptococci group B, Enterocooci, Staphylococci, Gram-negative aerobic bacteria, Escherichia coli, Pseudomonas aeruginosa, Enterobacter cloacae, Klebsilla, and Proteus were the different bacterial flora that were reported in the culture [Figure 8].
Figure 8: Bacterilogical culture of necrotizing fasciitis

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  Discussion Top

Literature search using Medical Subject Headings (MESH) terms "necrotizing fasciitis, counter irritant" did not return any scholarly article showing Counter irritant as an etiological agent in NF. In the absence of evidence the pathology of counter irritant induced NF can only be an educated guess. Cell injury results when cells are stressed so severely that they are no longer able to adapt or when cells are exposed to inherently damaging agents or suffer from intrinsic abnormalities. Different injurious stimuli affect many metabolic pathways and cellular organelles. Some chemicals act directly by combining with a critical molecular component or cellular organelle. An enormous number of chemical substances can injure cells; even innocuous substances such as glucose or salt, if sufficiently concentrated, can so derange the osmotic environment that cell injury or death results. Agents commonly known as poisons cause severe damage at the cellular level by altering membrane permeability, osmotic homeostasis, or the integrity of an enzyme or cofactor, and exposure to these poisons can culminate in the death of the whole organism. Even therapeutic drugs can cause cell or tissue injury in a susceptible patient or if used excessively or inappropriately. Toxin-induced vascular occlusion, a mechanism similar to that occurs in classical NF may also be the underlying cause. [10] We believe one of the above mechanisms alone or in combination is the underlying pathological pathway. Karpoor Powder, Gaultheria ka Tel, Nilgiri Ka Tel, Lavang oil, Pudinha and other plant resins are common ingredients that are used by different brands in various combinations. It needs to be investigated which one of the above compounds either alone or in combination was the culprit.

  Conclusions Top

The study strongly points the role of counterirritants in the etiology of NF. Either a cohort study or a case-control study is needed to prove the association between application of counterirritant and development of NF.

  References Top

1.Hippokrates: Zweites Buch Der Volkskrankheiten. vol. 8. Berlin: Springer Verlag; 1967. p. 20  Back to cited text no. 1
2.Loudon I. Necrotising fasciitis, hospital gangrene, and phagedena. Lancet 1994;344:1416-9.  Back to cited text no. 2
3.Meleney FL. Hemolytic streptococcal gangrene. Arch Surg 1924;9:317-64.  Back to cited text no. 3
4.Fournier AJ. Gangrene foudroyante de la verge. Sem Med 1883;3:345-8.  Back to cited text no. 4
5.Wilson B. Necrotizing fasciitis. Am Surg 1952;18:416-31.  Back to cited text no. 5
6.Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med 1996;334:240-5.  Back to cited text no. 6
7.Brown DR, Davis NL, Lepawsky M, Cunningham J, Kortbeek J. A multicenter review of the treatment of major truncal necrotizing infections with and without hyperbaric oxygen therapy. Am J Surg 1994;167:485-9.  Back to cited text no. 7
8.Schwartz B, Facklam RR, Breiman RF. Changing epidemiology of group A streptococcal infection in the USA. Lancet 1990;336:1167-71.  Back to cited text no. 8
9.Fisher JR, Conway MJ, Takeshita RT, Sandoval MR. Necrotizing fasciitis: Importance of roentgenographic studies for soft-tissue gas. JAMA 1979;241:803-6.  Back to cited text no. 9
10.Kumar, Abbas, Fausto, Mitchell. Overview of cellular response to stress and noxious stimuli. Robbins's Basic pathology. vol. 8. Philadelphia: Saundres Elselvier; 2011. p. 7.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

  [Table 1]


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